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1 Complete this Application only if you cannot apply online.

Find out if you are eligible to apply on online by going to “Join ASCAP,” at
It’s faster, more efficient, and facilitates ASCAP’s ability to communicate with you. Only if you are not eligible to
apply online should you proceed with using a paper application.

2 To proceed with the Paper Application, please fill out the attached four (4) forms:
❍ ASCAP Publisher Application
❍ ASCAP Membership Agreement
❍ ASCAP Application Processing Fee Form
❍ W-9 Form—Request for Taxpayer Identification Number and Certificate
(Required by the Internal Revenue Service)

3 Sign all four (4) forms. Keep a copy for your files.

The signature on the Agreement must match the signature on your Application. If you are under 18, a
parent’s or guardian’s signature is required on both the Agreement and Application.

4 Complete the application processing fee payment section:

There is a non-refundable processing fee of $75 due upon submission of your application. ASCAP will not process
your application without payment. You may pay by credit card, check or money order. Do not send cash.

5 Send all four (4) completed and signed forms together to:
Membership Application Enclosed, ASCAP, One Lincoln Plaza, New York, NY 10023


granted the right to license your works for performances in foreign countries to any other entity, please
provide us with a list showing each such country, the entity with which you have such an agreement, the
date the agreement expires, and any other pertinent information concerning that agreement.

TAX FORM: The IRS requires that ASCAP has accurate tax information on file for all members who are U.S.
COMPLETED AND SIGNED. If you use your Social Security Number for your publishing entity, your name and
Social Security Number (SS#) must match the name and number as they appear on your Social Security card.
If you have obtained a separate Tax ID# for your publishing entity, use this number on Form W-9.

If you are not a U.S. citizen or resident alien, you will need to fill out a W-8BEN Form. The W-8BEN Form can
be downloaded from the Internal Revenue Service’s website at: You can also request the
form by calling ASCAP’s Member Management Administration office in New York at (212) 621-6240.

acknowledge that you have read ASCAP's Articles of Association, Compendium of Rules and Regulations, and
the Second Amended Final Judgment entered in U.S. v. ASCAP ("AFJ2"). All of these documents are available
on our website at: ASCAP will also provide printed copies of these documents
upon request at no charge.

NOTIFICATION OF ACCEPTANCE. If you are elected to membership, you will receive notice of acceptance
along with your personalized ASCAP Member Card indicating your Member Code Number. A fully executed
copy of your agreement will be kept on record at ASCAP.

If there is a problem with your application, ASCAP’s Member Management Administration will contact you.


H-P-ENG-2009-10 ASCAP, One Lincoln Plaza, New York, NY 10023 (212) 621-6000 WWW.ASCAP.COM
1. COMPANY NAME: In order to collect your publishing royalty income, you must establish a publishing company with a unique name, and your
ASCAP publishing company CANNOT be affiliated with any other performing rights licensing organization. Please list four choices for this name in
order of preference, not to exceed 50 characters, including spaces. The first publishing company name in your order of preference which is “cleared”
for your use will be your ASCAP publishing company name. Names are checked according to pronunciation and various spellings. PLEASE NOTE: If
your publishing company will be a subsidiary of your corporation or LLC, you must include the corporation or LLC as part of the publishing company
name, e.g. ABC Corp. d/b/a XYZ Music Publishing Company. PLEASE ALLOW 2-3 WEEKS FOR THE CLEARANCE PROCESS.

C/O (if applicable)
Street Address Apt. #
City State Zip Country
Phone Number ( ) Fax Number ( )
* ASCAP will use your e-mail address for ASCAP correspondence only. We will not share or sell your e-mail address. You may opt out of receiving ASCAP e-mail
correspondence or change your email address at any time, but only after you have completed the application process and have been accepted as a member.
Please note: Publisher contact information for performed works will be listed in the ACE database on the ASCAP web site.

ROYALTY ADDRESS: (only if you would like your royalties and performance statements sent to a different address than above)
C/O (if applicable)
Street Address Apt. #
City State Zip Country
Phone Number ( ) Fax Number ( )


Individual Ownership/Sole Proprietorship (fill out A below)
Partnership or Joint Venture (fill out B and #4, below)
Corporation or Limited Liability Company (LLC) (fill out C and #4, below)




Please note: If you are providing a Social Security Number, it should be associated with your legal name.

Do you wish to have royalty checks made payable in the company’s name, or in your name? (check one)
Company name My name doing business as (d/b/a) Company name


Social Security numbers CANNOT be used as Tax ID numbers.

List All Partners or Co-Venturers (first name, last name)* Social Security # (for each partner or co-venturer listed)
(attach additional pages if needed)

__________________________________________________ ________________________________________
__________________________________________________ ________________________________________
__________________________________________________ ________________________________________

H-P-ENG-2009-10 ASCAP, One Lincoln Plaza, New York, NY 10023 (212) 621-6000 WWW.ASCAP.COM
Page 2

IMPORTANT NOTE: You CANNOT apply as a corporation if you have not registered as one with your state. Social Security numbers CANNOT be used as Tax ID numbers.

LIST ALL OFFICERS OR MEMBERS (first name, last name) AND TITLES* (attach additional pages if needed)

LIST ALL STOCKHOLDERS (corporations only) OR ALL OWNERS (LLC’s only)* (attach additional pages as needed)

Each publisher member, unless an individual ownership/sole proprietorship, must file the name of a person who will be the publisher’s representative,
for all purposes, to ASCAP (see Articles of Association, Article III, Section 10). This person must be an officer, partner, co-venturer or owner. Please
list this designated representative’s name and capacity below.
CAPACITY, i.e. officer (specify office held), partner, co-venturer or owner

5. If any of the individuals or entities listed in 3A, 3B or 3C are or have been members or affiliates of
ASCAP BMI SESAC or a foreign performing right licensing organization
please provide the following information: (if more than three individuals, attach additional pages if needed.)

If a publisher, please indicate:



To qualify for membership in ASCAP, you must be engaged in the music publishing business, and have assumed the financial risk involved
in the normal publication of musical works or own compositions regularly performed by ASCAP’s licensees (e.g., be the publisher of at least
one musical work or song that has been commercially recorded, performed publicly in any venue licensable by ASCAP, performed in any
audio visual or electronic medium, or available for sale or rental as sheet music, a score or folio).

Title of ONE musical work or song*:
* Entering the title of your work is solely for the purpose of substantiating your qualifications for ASCAP membership. A title registration with ASCAP for this work must be
submitted upon your membership election.

7. Please complete AT LEAST ONE of the following requirements (7A, 7B, 7C, 7D) that you as a publisher meet to
qualify for membership in ASCAP and provide the information requested based on the musical work or song listed
in number 6 above:
A. Public performance in any venue licensable by ASCAP (club, live concert, symphonic concert or recital venue, college
or university, etc.)
Name of Venue:
Date of Performance*: Location (city, state):
* The Date of Performance must be in the past. If you don’t have this qualification, you may be able to apply using another method of substantiation.

OR B. Performance in any audio visual or electronic medium (film, television, radio, Internet, cable, pay-per-view etc.)
Title or name of film, television program, website, radio station:
Date of Performance*:
* The Date of Performance must be in the past. If you don’t have this qualification, you may be able to apply using another method of substantiation.

H-P-ENG-2009-10 ASCAP, One Lincoln Plaza, New York, NY 10023 (212) 621-6000 WWW.ASCAP.COM
Page 3

OR C. A commercial recording
Recording Artist:
Date of Release*: Record Label (Includes independent or self releases):
* The Date of Release must be in the past. If you don’t have this qualification, you may be able to apply using another method of substantiation.

OR D. Published sheet music, score or folio available for sale or rental

Title of published sheet music, score or folio:

8. Please list the type of musical genre you primarily work in (check only one):
Popular, or
Symphonic/Concert Music (works for orchestra, chamber ensemble, chorus, wind ensemble, concert band,
solo instrumental, electro-acoustic forces, etc.).


A. Applicant warrants that the work listed in Item #6 above is a domestic or foreign copyrighted musical composition owned by Applicant
as of this date. If a foreign copyright, performing rights for the United States and Canada are owned by Applicant.
B. Applicant also hereby represents that there are no existing assignments or licenses, direct or indirect, of non-dramatic performing rights
in or to the musical work listed in Item #6 above accept for the assignments or licenses of which Applicant has attached true copies.
C. Applicant has read the ASCAP Articles of Association, Compendium of Rules and Regulations, and Second Amended Final Judgement
entered in U.S. vs ASCAP (“AFJ2”), and agrees to be bound by them, as now in effect, and as they may be amended, and Applicant
agrees to execute agreements in such form and for such periods as the Board of Directors shall have required and shall hereafter require
for all members.
D. Applicant represents that Applicant meets the eligibility requirements for publisher membership, as set forth herein. Applicant
understands that ASCAP reserves the right to request substantiation of eligibility at any time.
E. Applicant warrants and represents that all of the information furnished in this application is true. Applicant acknowledges that any
agreement entered into between ASCAP and the company will be in reliance upon the representations contained in this application, and
that this membership will be subject to termination if any information contained in this application is not complete and accurate, or if the
names of each owner, stockholder and officer are not provided as requested.

Optional: Publisher Digital Home Recording (“DART”) Royalties Election

Under the Audio Home Recording Act of 1992, royalties are paid by manufacturers and importers of digital audio recording equipment and recording
media (e.g., blank tapes or discs). The royalties are shared by writers, publishers, recording artists and record companies. ASCAP can act on behalf
of those members who specifically designate ASCAP to represent them in digital audio royalty matters under the Act. SEE DART FACT SHEET ON

YES, Applicant grants the American Society of Composers, Authors and Publishers (“ASCAP”) the exclusive right to collect and distribute digital
audio royalty payments as provided in Public Law No. 102-563 (the Audio Home Recording Act of 1992), as such law may be amended and
payments for home recording of Applicant’s copyrighted musical works outside of the United States, with respect to all of the musical works
described in the ASCAP Membership Agreement.
NO, Applicant does not wish ASCAP to represent me regarding home recording rights.


Sign Here Date

Signature of parent or guardian if applicant is under 18 Date

Membership Application Enclosed, ASCAP, One Lincoln Plaza, New York, NY 10023
❍ ASCAP Publisher Application (this form)
❍ ASCAP Membership Agreement
❍ W-9 Form or other applicable tax form. (See instructions.)
❍ Application Processing Fee Form. (See instructions.)


For ASCAP office use only: Card type/check #_____________________________ Transaction Code:__________________________________ Date:__________________________

H-P-ENG-2009-10 ASCAP, One Lincoln Plaza, New York, NY 10023 (212) 621-6000 WWW.ASCAP.COM
Page 4


APPLICATION PROCESSING FEE: There is a non-refundable processing fee of $75 due upon submission of your
application. ASCAP cannot process your application without payment of this fee. You may pay by credit card, check
or money order. Do not send cash.

If paying by check or money order, please make payable to ASCAP and staple or clip it here:

If paying by credit card, please complete the following information:

Cardholder Name:
Billing Address: Apt. #:
City: State: Zip: Country:

Card Type: Visa[ ] Mastercard[ ]

Card Number:
Card ID Number (This is the last 3-digit number on the back of your credit card. See illustration below):

Expiration Date: Month______ Year______

H-P-ENG-2009-10 ASCAP, One Lincoln Plaza, New York, NY 10023 (212) 621-6000 WWW.ASCAP.COM
DART (Digital Audio Recording Technology) Fact Sheet

The Audio Home Recording Act of 1992 created new royalty funds to be shared by writers, publishers, recording artists
and record companies. Royalties are paid by manufacturers and importers of digital audio recording equipment and
recording media (e.g., blank tapes or discs).

The royalties are then divided into two funds. One-third of the total paid is allocated to the Musical Works Fund. (The
other two-thirds is allocated to the Sound Recordings Fund, to be shared by recording artists and record companies.)
The Musical Works Fund is then subdivided 50-50 into a Writers Subfund and a Publishers Subfund. Royalties are
allocated to claimants within each subfund based on broadcast performances or phonorecord sales.

Royalties are allocated among the interested parties in each subfund as they agree or, in the absence of agreement, as
a Copyright Arbitration Royalty Panel and the Copyright Office decide.

ASCAP will act on behalf of those members who specifically designate ASCAP to represent them in digital audio
royalty matters under the Act. ASCAP’s services on behalf of those members include negotiations with other individual
and joint claimants to Musical Works Fund royalties to reach voluntary agreement for the fair and equitable distribution
of royalty payments. In the absence of such voluntary agreements, ASCAP will represent those members in distribution
proceedings before the Copyright Arbitration Royalty Panel, and seek the maximum award of royalties to which those
members are entitled. ASCAP will then distribute to those members the digital audio royalty payments collected.

ASCAP has a long and very successful track record in representing our members before the Copyright Arbitration
Royalty Panel and its predecessor entity, the Copyright Royalty Tribunal, in the collection and distribution of royalties
paid by users pursuant to the cable, satellite home carrier, jukebox and noncommercial broadcast compulsory licenses.
ASCAP is positioned, by virtue of our experience and the records we maintain in the ordinary course of business, to
provide these valuable additional services with respect to digital audio royalty payments to our membership.

ASCAP is able to render these services at minimal cost, primarily by using data we process in our routine survey of
radio feature performances. We also rely on retail sales data electronically gathered by a computerized information man-
agement network. We will also include in the amount to be distributed all interest earned while sums are in the process
of distribution, in keeping with ASCAP’s normal practice.

Claims to each year’s royalties must be filed in January or February of the next year. Thus, for example, claims to this
year’s royalties must be filed between January 1 and February 28 of next year.

You need not have ASCAP represent you in digital audio royalty distribution proceedings—you may appear individually,
or have another entity represent you. HOWEVER, IF YOU WANT ASCAP TO REPRESENT YOU, YOU MUST CHECK


If you have any questions, please contact our Member Services Department at 1-800-952-7227.

H-P-ENG-2009-10 ASCAP, One Lincoln Plaza, New York, NY 10023 (212) 621-6000 WWW.ASCAP.COM
Agreement made between the Undersigned (for brevity called “Owner”) operetta, musical comedy, play or like production was presented on
and the AMERICAN SOCIETY OF COMPOSERS, AUTHORS AND the stage or in motion picture form): provided, however, that the
PUBLISHERS (for brevity called “Society”), in consideration of the rights hereby granted shall be deemed to include a grant of the right
premises and of the mutual covenants hereinafter contained, as follows: to license non-dramatic performances of compositions by television
broadcasting of a motion picture containing such composition if the
1. The Owner grants to the Society for the term hereof, the right to rights in such motion picture other than those granted hereby have
license non-dramatic public performances (as hereinafter defined), been obtained from the parties in interest.
of each musical work:
(ii) Nothing herein contained shall be deemed to grant the right
Of which the Owner is a copyright proprietor; or to license the public performance by television broadcasting of
dramatic performances. Any performance of a separate musical
Which the Owner, alone, or jointly, or in collaboration with others, composition which is not a dramatic performance, as defined herein,
wrote, composed, published, acquired or owned; or shall be deemed to be a non-dramatic performance. For the purposes
of this agreement, a dramatic performance shall mean a performance
In which the Owner now has any right, title, interest or control of a musical composition on a television program in which there is a
whatsoever, in whole or in part; or definite plot depicted by action and where the performance of the
musical composition is woven into and carries forward the plot and
Which hereafter, during the term hereof, may be written, composed, its accompanying action. The use of dialogue to establish a mere
acquired, owned, published or copyrighted by the Owner, alone, program format or the use of any non-dramatic device merely to
jointly or in collaboration with others; or introduce a performance of a composition shall not be deemed to
make such performances dramatic.
In which the Owner may hereafter, during the term hereof, have any
right, title, interest or control, whatsoever, in whole or in part. (iii) The definition of the terms “dramatic” and “non-dramatic”
performances contained herein are purely for the purposes of this
The right to license the public performance of every such musical work agreement and for the term thereof and shall not be binding upon or
shall be deemed granted to the Society by this instrument for the term prejudicial to any position taken by either of us subsequent to the
hereof, immediately upon the work being written, composed, acquired, term hereof or for any purpose other than this agreement.
owned, published or copyrighted.
(e) The Owner may at any time and from time to time, in good faith,
The rights hereby granted shall include: restrict the radio or television broadcasting of compositions from
musical comedies, operas, operettas and motion pictures, or any
(a) All the rights and remedies for enforcing the copyright or copy- other composition being excessively broadcast, only for the purpose
rights of such musical works, whether such copyrights are in the of preventing harmful effect upon such musical comedies, operas,
name of the Owner and/or others, as well as the right to sue under operettas, motion pictures or compositions, in respect of other
such copyrights in the name of the Society and/or in the name of the interest under the copyrights thereof; provided, however, that the
Owner and/or others, to the end that the Society may effectively right to grant limited licenses will be given, upon application, as to
protect and be assured of all the rights hereby granted. restricted compositions, if and when the Owner is unable to show
reasonable hazards to his or its major interests likely to result from
(b) The non-exclusive right of public performance of the separate such radio or television broadcasting; and provided further that such
numbers, songs, fragments or arrangements, melodies or selections right to restrict any such composition shall not be exercised for the
forming part or parts of musical plays and dramatico-musical purpose of permitting the fixing or regulating of fees for the recording
compositions, the Owner reserving and excepting from this grant or transcribing of such composition, and provided further that in no
the right of performance of musical plays and dramatico-musical case shall any charges, “free plugs,” or other consideration be
compositions in their entirety, or any part of such plays or dramatico- required in respect of any permission granted to perform a restricted
musical compositions on the legitimate stage. composition; and provided further that in no event shall any
composition, after the initial radio or television broadcast thereof, be
(c) The non-exclusive right of public performance by means of radio restricted for the purpose of confining further radio or television
broadcasting, telephony, “wired wireless,” all forms of synchronism broadcasts thereof to a particular artist, station, network or program.
with motion pictures, and/or any method of transmitting sound other The Owner may also at anytime and from time to time, in good faith,
than television broadcasting. restrict the radio or television broadcasting of any composition, as to
which any suit has been brought or threatened on a claim that such
(d) The non-exclusive right of public performance by television composition infringes a composition not contained in the repertory of
broadcasting; provided, however, that: Society or on a claim by a non-member of Society that Society does
not have the right to license the public performance of such
(i) This grant does not extend to or include the right to license composition by radio or television broadcasting.
the public performance by television broadcasting or otherwise of
any rendition or performance of (a) any opera, operetta, musical 2. The term of this Agreement shall be for a period commencing on the
comedy, play or like production, as such, in whole or in part, or (b) date hereof and continuing indefinitely thereafter unless terminated by
any composition from any opera, operetta, musical comedy, play either party in accordance with the Articles of Association.
or like production (whether or not such opera, operetta, musical
comedy, play or like production was presented on the stage or in 3. The Society agrees, during the term hereof, in good faith to use its
motion picture form) in a manner which recreates the performance best endeavors to promote and carry out the objects for which it was
of such composition with substantially such distinctive scenery or organized, and to hold and apply all royalties, profits, benefits and
costume as was used in the presentation of such opera, operetta, advantages arising from the exploitation of the rights assigned to it by
musical comedy, play or like production (whether or not such opera, its several members, including the Owner, to the uses and purposes as
provided in its Articles of Association (which are hereby incorporated by system of apportionment and distribution of royalties as determined by
reference), as now in force or as hereafter amended. the Board of Directors in accordance with the Articles of Association as
they may be amended from time to time.
4. The Owner hereby irrevocably, during the term hereof, authorizes,
empowers and vests in the Society the right to enforce and protect such 8. The Owner agrees that the apportionment and distribution of royalties
rights of public performance under any and all copyrights, whether by the Society as determined from time to time by the Board of Directors
standing in the name of the Owner and/or others, in any and all works of the Society, in case of appeal by him, shall be final, conclusive and
copyrighted by the Owner, and/or by others; to prevent the infringement binding upon him. The Society shall have the right to transfer the right of
thereof, to litigate, collect and receipt for damages arising from infringe- review of any apportionment and distribution of royalties from the Board
ment, and in its sole judgment to join the Owner and/or others in whose of Directors to any other agency or instrumentality that in its discretion
names the copyright may stand, as parties plaintiff or defendants in suits and good judgment it deems best adapted to assuring to the Society’s
or proceedings; to bring suit in the name of the Owner and/or in the membership a just, fair, equitable and accurate apportionment and
name of the Society, or others in whose name the copyright may stand, distribution of royalties. The Society shall have the right to adopt from
or otherwise, and to release, compromise, or refer to arbitration any time to time such systems, means, methods and formulae for the
actions, in the same manner and to the same extent and to all intents establishment of a member’s apportionment and distribution of royalties
and purposes as the Owner might or could do, had this instrument not as will assure a fair, just and equitable distribution of royalties among
been made. the membership.

5. The Owner hereby makes, constitutes and appoints the Society, or its 9. “Public Performance” Defined. The term “public performance” shall
successor, the Owner’s true and lawful attorney, irrevocably during the be construed to mean vocal, instrumental and/or mechanical renditions
term hereof, and in the name of the Society or its successor, or in the and representations in any manner or by any method whatsoever,
name of the Owner, or otherwise, to do all acts, take all proceedings, including transmissions by radio and television broadcasting stations,
execute, acknowledge and deliver any and all instruments, papers, transmission by telephony and/or “wired wireless”; and/or reproductions
documents, process and pleadings that may be necessary, proper or of performances and renditions by means of devices for reproducing
expedient to restrain infringements and recover damages in respect to or sound recorded in synchronism or timed relation with the taking of
for the infringement or other violation of the rights of public performance motion pictures.
in such works, and to discontinue, compromise or refer to arbitration any
such proceedings or actions, or to make any other disposition of the 10. “Musical Works” Defined. The phrase “musical works” shall be
differences in relation to the premises. construed to mean musical compositions and dramatico-musical
compositions, the words and music thereof, and the respective
6. The Owner agrees from time to time, to execute, acknowledge and arrangements thereof, and the selections therefrom.
deliver to the Society, such assurances, powers of attorney or other
authorizations or instruments as the Society may deem necessary or 11. The powers, rights, authorities and privileges by this instrument
expedient to enable it to exercise, enjoy and enforce, in its own name or vested in the Society, are deemed to include the World, provided,
otherwise, all rights and remedies aforesaid. however, that such grant of rights for foreign countries shall be subject
to any agreements now in effect, a list of which is attached hereto.
7. It is mutually agreed that during the term hereof the Board of Directors
of the Society shall be composed of an equal number of writers and 12. The grant made herein by the Owner is modified by and subject to
publishers respectively, and that the royalties distributed by the Board of the provisions of (a) the Second Amended Final Judgment in United
Directors shall be divided into two (2) equal sums, and one (1) each of States vs ASCAP, Civ. Action No. 41-1395 (S.D.N.Y. June 11, 2001), as
such sums credited respectively to and for division amongst (a) the the same may be amended from time to time, and (b) the provisions of
writer members, and (b) the publisher members, in accordance with the the Articles of Association and resolutions of the Board of Directors.


day month year








One Lincoln Plaza, New York, NY 10023 ●
(212) 621-6000
(Rev. November 2005)
W-9 Request for Taxpayer Give form to the
requester. Do not
Department of the Treasury
Identification Number and Certification send to the IRS.
Internal Revenue Service
Name (as shown on your income tax return)
See Specific Instructions on page 2.

Business name, if different from above

Print or type

Individual/ 䊳
Exempt from backup
Corporation Partnership Other
Check appropriate box: Sole proprietor withholding
Address (number, street, and apt. or suite no.) Requester’s name and address (optional)

City, state, and ZIP code

List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid Social security number
backup withholding. For individuals, this is your social security number (SSN). However, for a resident – –
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. or
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification number
number to enter. –
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. (See the instructions on page 4.)

Sign Signature of
Here U.S. person 䊳 Date 䊳

Purpose of Form ● An individual who is a citizen or resident of the United

A person who is required to file an information return with the States,
IRS, must obtain your correct taxpayer identification number ● A partnership, corporation, company, or association
(TIN) to report, for example, income paid to you, real estate created or organized in the United States or under the laws
transactions, mortgage interest you paid, acquisition or of the United States, or
abandonment of secured property, cancellation of debt, or ● Any estate (other than a foreign estate) or trust. See
contributions you made to an IRA. Regulations sections 301.7701-6(a) and 7(a) for additional
U.S. person. Use Form W-9 only if you are a U.S. person information.
(including a resident alien), to provide your correct TIN to the Special rules for partnerships. Partnerships that conduct a
person requesting it (the requester) and, when applicable, to: trade or business in the United States are generally required
1. Certify that the TIN you are giving is correct (or you are to pay a withholding tax on any foreign partners’ share of
waiting for a number to be issued), income from such business. Further, in certain cases where a
2. Certify that you are not subject to backup withholding, or Form W-9 has not been received, a partnership is required to
presume that a partner is a foreign person, and pay the
3. Claim exemption from backup withholding if you are a withholding tax. Therefore, if you are a U.S. person that is a
U.S. exempt payee. partner in a partnership conducting a trade or business in the
In 3 above, if applicable, you are also certifying that as a United States, provide Form W-9 to the partnership to
U.S. person, your allocable share of any partnership income establish your U.S. status and avoid withholding on your
from a U.S. trade or business is not subject to the share of partnership income.
withholding tax on foreign partners’ share of effectively
connected income. The person who gives Form W-9 to the partnership for
purposes of establishing its U.S. status and avoiding
Note. If a requester gives you a form other than Form W-9 to withholding on its allocable share of net income from the
request your TIN, you must use the requester’s form if it is partnership conducting a trade or business in the United
substantially similar to this Form W-9. States is in the following cases:
For federal tax purposes, you are considered a person if you ● The U.S. owner of a disregarded entity and not the entity,
Cat. No. 10231X Form W-9 (Rev. 11-2005)
Form W-9 (Rev. 11-2005) Page 2
● The U.S. grantor or other owner of a grantor trust and not 3. The IRS tells the requester that you furnished an
the trust, and incorrect TIN,
● The U.S. trust (other than a grantor trust) and not the 4. The IRS tells you that you are subject to backup
beneficiaries of the trust. withholding because you did not report all your interest and
Foreign person. If you are a foreign person, do not use dividends on your tax return (for reportable interest and
Form W-9. Instead, use the appropriate Form W-8 (see dividends only), or
Publication 515, Withholding of Tax on Nonresident Aliens 5. You do not certify to the requester that you are not
and Foreign Entities). subject to backup withholding under 4 above (for reportable
interest and dividend accounts opened after 1983 only).
Nonresident alien who becomes a resident alien.
Generally, only a nonresident alien individual may use the Certain payees and payments are exempt from backup
terms of a tax treaty to reduce or eliminate U.S. tax on withholding. See the instructions below and the separate
certain types of income. However, most tax treaties contain a Instructions for the Requester of Form W-9.
provision known as a “saving clause.” Exceptions specified Also see Special rules regarding partnerships on page 1.
in the saving clause may permit an exemption from tax to
continue for certain types of income even after the recipient Penalties
has otherwise become a U.S. resident alien for tax purposes. Failure to furnish TIN. If you fail to furnish your correct TIN
If you are a U.S. resident alien who is relying on an to a requester, you are subject to a penalty of $50 for each
exception contained in the saving clause of a tax treaty to such failure unless your failure is due to reasonable cause
claim an exemption from U.S. tax on certain types of income, and not to willful neglect.
you must attach a statement to Form W-9 that specifies the Civil penalty for false information with respect to
following five items: withholding. If you make a false statement with no
1. The treaty country. Generally, this must be the same reasonable basis that results in no backup withholding, you
treaty under which you claimed exemption from tax as a are subject to a $500 penalty.
nonresident alien. Criminal penalty for falsifying information. Willfully
2. The treaty article addressing the income. falsifying certifications or affirmations may subject you to
3. The article number (or location) in the tax treaty that criminal penalties including fines and/or imprisonment.
contains the saving clause and its exceptions. Misuse of TINs. If the requester discloses or uses TINs in
4. The type and amount of income that qualifies for the violation of federal law, the requester may be subject to civil
exemption from tax. and criminal penalties.
5. Sufficient facts to justify the exemption from tax under
the terms of the treaty article. Specific Instructions
Example. Article 20 of the U.S.-China income tax treaty Name
allows an exemption from tax for scholarship income
received by a Chinese student temporarily present in the If you are an individual, you must generally enter the name
United States. Under U.S. law, this student will become a shown on your income tax return. However, if you have
resident alien for tax purposes if his or her stay in the United changed your last name, for instance, due to marriage
States exceeds 5 calendar years. However, paragraph 2 of without informing the Social Security Administration of the
the first Protocol to the U.S.-China treaty (dated April 30, name change, enter your first name, the last name shown on
1984) allows the provisions of Article 20 to continue to apply your social security card, and your new last name.
even after the Chinese student becomes a resident alien of If the account is in joint names, list first, and then circle,
the United States. A Chinese student who qualifies for this the name of the person or entity whose number you entered
exception (under paragraph 2 of the first protocol) and is in Part I of the form.
relying on this exception to claim an exemption from tax on Sole proprietor. Enter your individual name as shown on
his or her scholarship or fellowship income would attach to your income tax return on the “Name” line. You may enter
Form W-9 a statement that includes the information your business, trade, or “doing business as (DBA)” name on
described above to support that exemption. the “Business name” line.
If you are a nonresident alien or a foreign entity not subject Limited liability company (LLC). If you are a single-member
to backup withholding, give the requester the appropriate LLC (including a foreign LLC with a domestic owner) that is
completed Form W-8. disregarded as an entity separate from its owner under
What is backup withholding? Persons making certain Treasury regulations section 301.7701-3, enter the owner’s
payments to you must under certain conditions withhold and name on the “Name” line. Enter the LLC’s name on the
pay to the IRS 28% of such payments (after December 31, “Business name” line. Check the appropriate box for your
2002). This is called “backup withholding.” Payments that filing status (sole proprietor, corporation, etc.), then check
may be subject to backup withholding include interest, the box for “Other” and enter “LLC” in the space provided.
dividends, broker and barter exchange transactions, rents, Other entities. Enter your business name as shown on
royalties, nonemployee pay, and certain payments from required federal tax documents on the “Name” line. This
fishing boat operators. Real estate transactions are not name should match the name shown on the charter or other
subject to backup withholding. legal document creating the entity. You may enter any
You will not be subject to backup withholding on payments business, trade, or DBA name on the “Business name” line.
you receive if you give the requester your correct TIN, make Note. You are requested to check the appropriate box for
the proper certifications, and report all your taxable interest your status (individual/sole proprietor, corporation, etc.).
and dividends on your tax return.
Payments you receive will be subject to backup Exempt From Backup Withholding
withholding if: If you are exempt, enter your name as described above and
1. You do not furnish your TIN to the requester, check the appropriate box for your status, then check the
2. You do not certify your TIN when required (see the Part “Exempt from backup withholding” box in the line following
II instructions on page 4 for details), the business name, sign and date the form.
Form W-9 (Rev. 11-2005) Page 3
Generally, individuals (including sole proprietors) are not Part I. Taxpayer Identification
exempt from backup withholding. Corporations are exempt
from backup withholding for certain payments, such as Number (TIN)
interest and dividends. Enter your TIN in the appropriate box. If you are a resident
Note. If you are exempt from backup withholding, you alien and you do not have and are not eligible to get an SSN,
should still complete this form to avoid possible erroneous your TIN is your IRS individual taxpayer identification number
backup withholding. (ITIN). Enter it in the social security number box. If you do
not have an ITIN, see How to get a TIN below.
Exempt payees. Backup withholding is not required on any
payments made to the following payees: If you are a sole proprietor and you have an EIN, you may
enter either your SSN or EIN. However, the IRS prefers that
1. An organization exempt from tax under section 501(a), you use your SSN.
any IRA, or a custodial account under section 403(b)(7) if the
account satisfies the requirements of section 401(f)(2), If you are a single-owner LLC that is disregarded as an
entity separate from its owner (see Limited liability company
2. The United States or any of its agencies or (LLC) on page 2), enter your SSN (or EIN, if you have one). If
instrumentalities, the LLC is a corporation, partnership, etc., enter the entity’s
3. A state, the District of Columbia, a possession of the EIN.
United States, or any of their political subdivisions or
Note. See the chart on page 4 for further clarification of
name and TIN combinations.
4. A foreign government or any of its political subdivisions,
agencies, or instrumentalities, or How to get a TIN. If you do not have a TIN, apply for one
immediately. To apply for an SSN, get Form SS-5,
5. An international organization or any of its agencies or Application for a Social Security Card, from your local Social
instrumentalities. Security Administration office or get this form online at
Other payees that may be exempt from backup You may also get this form by
withholding include: calling 1-800-772-1213. Use Form W-7, Application for IRS
6. A corporation, Individual Taxpayer Identification Number, to apply for an
7. A foreign central bank of issue, ITIN, or Form SS-4, Application for Employer Identification
8. A dealer in securities or commodities required to register Number, to apply for an EIN. You can apply for an EIN online
in the United States, the District of Columbia, or a by accessing the IRS website at and
possession of the United States, clicking on Employer ID Numbers under Related Topics. You
9. A futures commission merchant registered with the can get Forms W-7 and SS-4 from the IRS by visiting
Commodity Futures Trading Commission, or by calling 1-800-TAX-FORM
10. A real estate investment trust, If you are asked to complete Form W-9 but do not have a
11. An entity registered at all times during the tax year TIN, write “Applied For” in the space for the TIN, sign and
under the Investment Company Act of 1940, date the form, and give it to the requester. For interest and
12. A common trust fund operated by a bank under dividend payments, and certain payments made with respect
section 584(a), to readily tradable instruments, generally you will have 60
days to get a TIN and give it to the requester before you are
13. A financial institution, subject to backup withholding on payments. The 60-day rule
14. A middleman known in the investment community as a does not apply to other types of payments. You will be
nominee or custodian, or subject to backup withholding on all such payments until you
15. A trust exempt from tax under section 664 or provide your TIN to the requester.
described in section 4947. Note. Writing “Applied For” means that you have already
The chart below shows types of payments that may be applied for a TIN or that you intend to apply for one soon.
exempt from backup withholding. The chart applies to the Caution: A disregarded domestic entity that has a foreign
exempt recipients listed above, 1 through 15. owner must use the appropriate Form W-8.
IF the payment is for . . . THEN the payment is exempt
for . . .

Interest and dividend payments All exempt recipients except

for 9

Broker transactions Exempt recipients 1 through 13.

Also, a person registered under
the Investment Advisers Act of
1940 who regularly acts as a

Barter exchange transactions Exempt recipients 1 through 5

and patronage dividends

Payments over $600 required Generally, exempt

to be reported and direct 1 through 7
sales over $5,000 1
See Form 1099-MISC, Miscellaneous Income, and its instructions.
However, the following payments made to a corporation (including gross
proceeds paid to an attorney under section 6045(f), even if the attorney is a
corporation) and reportable on Form 1099-MISC are not exempt from
backup withholding: medical and health care payments, attorneys’ fees; and
payments for services paid by a federal executive agency.
Form W-9 (Rev. 11-2005) Page 4
Part II. Certification What Name and Number To Give the
To establish to the withholding agent that you are a U.S. Requester
person, or resident alien, sign Form W-9. You may be
For this type of account: Give name and SSN of:
requested to sign by the withholding agent even if items 1, 4,
and 5 below indicate otherwise. 1. Individual The individual
For a joint account, only the person whose TIN is shown in 2. Two or more individuals (joint The actual owner of the account
Part I should sign (when required). Exempt recipients, see account) or, if combined funds, the first
Exempt From Backup Withholding on page 2. individual on the account 1
Signature requirements. Complete the certification as 3. Custodian account of a minor The minor 2
indicated in 1 through 5 below. (Uniform Gift to Minors Act)
4. a. The usual revocable The grantor-trustee
1. Interest, dividend, and barter exchange accounts savings trust (grantor is
opened before 1984 and broker accounts considered also trustee)
active during 1983. You must give your correct TIN, but you b. So-called trust account The actual owner 1

do not have to sign the certification. that is not a legal or valid

2. Interest, dividend, broker, and barter exchange trust under state law
accounts opened after 1983 and broker accounts 5. Sole proprietorship or The owner
considered inactive during 1983. You must sign the single-owner LLC
certification or backup withholding will apply. If you are For this type of account: Give name and EIN of:
subject to backup withholding and you are merely providing 3
6. Sole proprietorship or The owner
your correct TIN to the requester, you must cross out item 2 single-owner LLC
in the certification before signing the form. 4
7. A valid trust, estate, or Legal entity
3. Real estate transactions. You must sign the pension trust
certification. You may cross out item 2 of the certification. 8. Corporate or LLC electing The corporation
4. Other payments. You must give your correct TIN, but corporate status on Form
you do not have to sign the certification unless you have 8832
been notified that you have previously given an incorrect TIN. 9. Association, club, religious, The organization
“Other payments” include payments made in the course of charitable, educational, or
the requester’s trade or business for rents, royalties, goods other tax-exempt organization
(other than bills for merchandise), medical and health care 10. Partnership or multi-member The partnership
services (including payments to corporations), payments to a LLC
nonemployee for services, payments to certain fishing boat 11. A broker or registered The broker or nominee
crew members and fishermen, and gross proceeds paid to nominee
attorneys (including payments to corporations). 12. Account with the Department The public entity
of Agriculture in the name of
5. Mortgage interest paid by you, acquisition or a public entity (such as a
abandonment of secured property, cancellation of debt, state or local government,
qualified tuition program payments (under section 529), school district, or prison) that
IRA, Coverdell ESA, Archer MSA or HSA contributions or receives agricultural program
distributions, and pension distributions. You must give payments
your correct TIN, but you do not have to sign the
certification. 1
List first and circle the name of the person whose number you furnish. If
only one person on a joint account has an SSN, that person’s number must
be furnished.
Circle the minor’s name and furnish the minor’s SSN.
You must show your individual name and you may also enter your business
or “DBA” name on the second name line. You may use either your SSN or
EIN (if you have one). If you are a sole proprietor, IRS encourages you to
use your SSN.
List first and circle the name of the legal trust, estate, or pension trust. (Do
not furnish the TIN of the personal representative or trustee unless the legal
entity itself is not designated in the account title.) Also see Special rules
regarding partnerships on page 1.
Note. If no name is circled when more than one name is
listed, the number will be considered to be that of the first
name listed.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns
with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or
abandonment of secured property, cancellation of debt, or contributions you made to an IRA, or Archer MSA or HSA. The IRS
uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this
information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S.
possessions to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, to federal
and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat
You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable
interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply.